UNITED DOCTORS MEDICAL CENTER Documentary Code #

Department of Nursing Service NSO:4-A

No. 290 Espana, cor. 6N. Ramirez St. Quezon City
Tel.No. 712-36-40 to 59 Revision Date
05/17/18

CHIEF COMPLAINT:__________________________________
I. LOC:___________________PUPILS(size)_________________REACTION:______________
II.VITAL SIGN :
BP_______RR_______RR________TEMP.__________WEIGHT_______HEIGHT_________
III.MODE OF ADMISSION
( ) Ambulatory ( ) Wheelchair ( ) Stretcher

Medication Date Time Given IV Bottle IV Fluid Date & Time

By No. Name Started

___________________________________________________________________________ IV.
A. MEDICATION B. INTRAVENOUS FLUID
C. OXYGEN THERAPY ______________________________
V. DIAGNOSTIC
A. X-RAY CT Scan B. LABORATORY C. ULTRASOUND
(Please specify)
_____Chest _______ ______PD1 _______________
_____Skull ______PD2 _______________
_____Abdomen Other (Pls. specify) D. Others
Others (Pls. specify) _______ABG
_______ECG
VI. PROCEDURE/ TREAMENT
____Intubation _____Nebulizer ______Suturing
ET Size ___Time___ (Pls. specify) ______Internal Exam
_____NGT __________ ______Rectal Exam
___w/lavage ____Suctioning others
___w/o lavage _____Oral (Pls. specify)
_____Foley Catheter _____Nasal _________
_____indwelling ______Thoracentesis _________
_____condom cath. ______Thoracostomy
By:_________ MD. By. ___________ MD.
VII. TO: Room ______ICU______LR ______ OR _____
Attending Physician____________________
Attending ROD________________ Nurse on Duty
____________________________ (
Signature over printed name)
______________________________________________________________________________
Patient Name: _________________________________________Hospital No._______________
Last Name First Name Middle Name
Age:_____________ Sex: ________________ Room
No._______________ Attending Physician:
____________________ Date/Time Admitted (Unit)__________________
 DATE TIME SPECIAL NOTATION NARRATIVE

Endorsing ER/OPD Nurse : _________________________

ER/OPD
WARD
NURSE:____________________________________
WARD NURSE
LEGEND : PUPILS Alert : Oriented to time , person and consciousness, easily
response to verbal command, speaks
clearly, Reaction to light:
answers , questions appropriately.
Drowsy: Diminished level of consciousness, easily,
awakened and responsive t minimal stimulation BR-Brisk
but prefer to sleep when undisturbed.
NR- No reaction Stuporous: Significantly decreased level of consciousness,
stimulation elicit brief purposeful confused
SIZE: response.
Comatose : Unresponsive even to painful stimuli.

Pinpoint 1-2mm 3-4mm 5-6mm 7-10mm